DSM-5 Released Today

By Ryan Jaslow & Michelle Castillo

Controversial update to psychiatry manual, DSM-5, arrivesThe controversial revision to psychiatrists’ “bible” of diagnostic criteria has finally arrived. The American Psychiatric Association released its fifth edition of the Diagnostic and Statistical Manual of Mental Disorders, or dubbed simply as the “DSM-5.”

The manual’s release was coincided with the APA’s annual meeting that kicked off May 18 in San Francisco.

The first major revision to the manual in almost two decades, the new DSM has been met by controversy since reports of proposed changes started to crop up last March.

Doctors often utilize the DSM to diagnose mental health disorders in patients that meet a specific set of criteria.

Among the major changes that garnered the most controversy was dropping Asperger’s syndrome, child disintegrative disorder and pervasive developmental disorder not otherwise specified (PDD), and included them under the blanket diagnosis of autism spectrum disorder.

Revisions were also made to diagnostic criteria for mental health disorders including schizophrenia, bipolar disorder, dissociative identity disorder and depressive disorders.

For example, in the last version of the manual, the 1994 DSM-IV, there was was an exclusion criterion for a major depressive episode that was applied to people with symptoms of depression lasting less than 2 months following the death of a loved one. The DSM-5 removed this after the APA realized since the last version that grief can last up to two years, and bereavement can be a severe psychological stressor that triggers depression, rather than an exception.

Besides worrying some mental health advocates over concerns changes in their diagnosis would affect their abilities to get treatment for state funding, the manual’s release also pitted the government’s National Institute of Mental Health (NIMH) and the American Psychiatric Association (APA),

NIMH director Thomas Insel wrote in a statement in early May that the NIMH felt the proposed definitions for psychiatric disorders were too broad and ignore smaller disorders that were lumped in with a larger diagnosis.

“The weakness is its lack of validity. Unlike our definitions of ischemic heart disease, lymphoma, or AIDS, the DSM diagnoses are based on a consensus about clusters of clinical symptoms, not any objective laboratory measure. In the rest of medicine, this would be equivalent to creating diagnostic systems based on the nature of chest pain or the quality of fever,” he wrote.

The government agency said it would use a different classification system, the Research Domain Criteria (RDoC) project, instead for its studies.

The NIH and APA released a joint statement on May 13, saying that “patients, families, and insurers can be confident that effective treatments are available and that the DSM is the key resource for delivering the best available care.” But, the statement also said, “The National Institute of Mental Health (NIMH) has not changed its position on DSM-5.”

A petition was also started by doctors to protest the new DSM.

One vocal critic, Dr. Allen Frances, who co-authored the DSM-IV, told CBS This Morning on Thursday that we are over-treating people in this country who are “basically well” and are “shamefully neglecting” people with mental disorders who are really sick, including one million people in prison with psychiatric disorders. The new manual, he said, is too loose for its diagnoses.

He said the average diagnosis is being given by a primary care doctor in a seven minute visit.

“People who are basically normal are getting all kinds of medicine that they don’t need that makes them worse and it is a terrible drain on the economy,” Frances said.

“I’m very curious to see what happens because as you know there’s kind of this tension between the DSM and some of the new NIMH initiatives,” Dr. James Murrough, an assistant professor of psychiatry and neuroscience at Mount Sinai Hospital in New York City, told CBSNews.com Murrough was not involved in the new DSM, but will be presenting research at the APA meeting this weekend.

He said by now, some psychiatrists had hoped the new DSM would contain more information about scientific tests or scans for psychologists or psychiatrists to help aid their diagnoses. But, he added the new version doesn’t appear to look very different from the last one.

“I think everyone is kind of disappointed that we don’t have that yet,” he said.

More information about the DSM-5 can be found on the APA’s website.

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Final DSM 5 Approved by American Psychiatric Association

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Final DSM 5 Approved by American Psychiatric AssociationYesterday, the board of trustees of the American Psychiatric Association (APA) approved a set of updates, revisions and changes to the reference manual used to diagnose mental disorders. The revision of the manual, called the Diagnostic and Statistical Manual of Mental Disorders and abbreviated as the DSM, is the first significant update in nearly two decades.

Disorders that will be in the new DSM-5 — but only in Section 3, a category of disorders needing further research — include: Attenuated psychosis syndrome, Internet use gaming disorder, Non-suicidal self-injury, and Suicidal behavioral disorder. Section 3 disorders generally won’t be reimbursed by insurance companies for treatment, since they are still undergoing research and revision to their criteria.

So here’s a list of the major updates…

Overall Changes to the DSM

According to the American Psychiatric Association’s statement, there are two major changes to the overall DSM — the dumping of the multiaxial system, and rearranging the chapter order of disorders. Most clinicians only paid attention to Axis I and II, so it’s no surprise the Axis system was never a big hit. The current chapter order has always been a bit of a mystery to most clinicians, so it’s good to know there’s some thought going into the new order of chapters.

Chapter order:

DSM-5’s 20 chapters will be restructured based on disorders’ apparent relatedness to one another, as reflected by similarities in disorders’ underlying vulnerabilities and symptom characteristics.

The changes will align DSM-5 with the World Health Organization’s (WHO) International Classification of Diseases, eleventh edition (ICD-11) and are expected to facilitate improved communication and common use of diagnoses across disorders within chapters.

Removal of multiaxial system:

DSM-5 will move to a nonaxial documentation of diagnosis, combining the former Axes I, II, and III, with separate notations for psychosocial and contextual factors (formerly Axis IV) and disability (formerly Axis V).

Specific Disorders

Autistic disorders will undergo a reshuffling and renaming:

“[Autism] criteria will incorporate several diagnoses from DSM-IV including autistic disorder, Asperger’s disorder, childhood disintegrative disorder and pervasive developmental disorder (not otherwise specified) into the diagnosis of autism spectrum disorder for DSM-5 to help more accurately and consistently diagnose children with autism,” according to an APA statement Saturday.

The rest of this update comes from the APA’s news release on the changes:

Binge eating disorder will be moved from DSM-IV’s Appendix B: Criteria Sets and Axes Provided for Further Study to DSM-5 Section 2. The change is intended to better represent the symptoms and behaviors of people with this condition.

This means binge eating disorder is now a real, recognized mental disorder.

Disruptive mood dysregulation disorder will be included in DSM-5 to diagnose children who exhibit persistent irritability and frequent episodes of behavior outbursts three or more times a week for more than a year.

The diagnosis is intended to address concerns about potential over-diagnosis and overtreatment of bipolar disorder in children. Will children now stop being diagnosed with bipolar disorder, which has been a recurring concern among many clinicians and researchers? We will see.

Excoriation (skin-picking) disorder is new to DSM-5 and will be included in the Obsessive-Compulsive and Related Disorders chapter.

Hoarding disorder is new to DSM-5.

Its addition to DSM is supported by extensive scientific research on this disorder. This disorder will help characterize people with persistent difficulty discarding or parting with possessions, regardless of their actual value. The behavior usually has harmful effects — emotional, physical, social, financial and even legal — for a hoarder and family members.

Pedophilic disorder criteria will remain unchanged from DSM-IV, but the disorder name will be revised from pedophilia to pedophilic disorder.

Personality disorders:

DSM-5 will maintain the categorical model and criteria for the 10 personality disorders included in DSM-IV and will include the new trait-specific methodology in a separate area of Section 3 to encourage further study how this could be used to diagnose personality disorders in clinical practice.

Posttraumatic stress disorder (PTSD) will be included in a new chapter in DSM-5 on Trauma- and Stressor-Related Disorders.

DSM-5 pays more attention to the behavioral symptoms that accompany PTSD and proposes four distinct diagnostic clusters instead of three. PTSD will also be more developmentally sensitive for children and adolescents.

Removal of bereavement exclusion:

The exclusion criterion in DSM-IV applied to people experiencing depressive symptoms lasting less than two months following the death of a loved one has been removed and replaced by several notes within the text delineating the differences between grief and depression. This reflects the recognition that bereavement is a severe psychosocial stressor that can precipitate a major depressive episode beginning soon after the loss of a loved one.

Specific learning disorder broadens the DSM-IV criteria to represent distinct disorders which interfere with the acquisition and use of one or more of the following academic skills: oral language, reading, written language, or mathematics.

Substance use disorder will combine the DSM-IV categories of substance abuse and
substance dependence. In this one overarching disorder, the criteria have not only been combined, but strengthened. Previous substance abuse criteria required only one symptom while the DSM-5’s mild substance use disorder requires two to three symptoms.

The APA board of trustees also outright rejected some new disorder ideas. The following disorders won’t appear anywhere in the new DSM-5:

  • Anxious depression
  • Hypersexual disorder
  • Parental alienation syndrome
  • Sensory processing disorder

Although clinicians are “treating” these concerns, the board of trustees felt like there wasn’t even enough research to consider putting them in Section 3 of the new DSM (disorders needing further research).

So there you have it. What do you think about these final decisions for the DSM-5?

 

Read the full list of changes from the APA: American Psychiatric Association Board of Trustees Approves DSM-5 (PDF)

Read the full article: Psychiatric association approves changes to diagnostic manual

Source: http://psychcentral.com/blog/archives/2012/12/02/final-dsm-5-approved-by-american-psychiatric-association/

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Not Diseases, but Categories of Suffering

By GARY GREENBERG

Not Diseases, but Categories of SufferingYOU’VE got to feel sorry for the American Psychiatric Association, at least for a moment. Its members proposed a change to the definition of autism in the fifth edition of their Diagnostic and Statistical Manual of Mental Disorders, one that would eliminate the separate category of Asperger syndrome in 2013. And the next thing they knew, a prominent psychiatrist was quoted in a front-page article in this paper saying the result would be fewer diagnoses, which would mean fewer troubled children eligible for services like special education and disability payments.

Then, just a few days later, another front-pager featured a pair of equally prominent experts explaining their smackdown of the A.P.A.’s proposal to eliminate the “bereavement exclusion” — the two months granted the grieving before their mourning can be classified as “major” depression. This time, the problem was that the move would raise the numbers of people with the diagnosis, increasing health care costs and the use of already pervasive mind-altering drugs, as well as pathologizing a normal life experience.

Fewer patients, more patients: the A.P.A. just can’t win. Someone is always mad at it for its diagnostic manual.

It’s not the current A.P.A.’s fault. The fault lies with its predecessors. The D.S.M. is the offspring of odd bedfellows: the medical industry, with its focus on germs and other biochemical causes of disease, and psychoanalysis, the now-largely-discredited discipline that attributes our psychological suffering to our individual and collective history.

This tension has been high since at least 1917. That’s when Thomas Salmon, a future head of the A.P.A. — which was founded in 1844 — noted that psychiatry’s “classification of mental diseases is chaotic.” He worried that “this condition of affairs discredits the science of psychiatry and reflects unfavorably upon our association” and urged his membership to forge a diagnostic system “that would meet the scientific demands of the present day.”

The American Psychiatric Association has been trying to do just that ever since, mostly by leaving behind ideas about the meaning of our suffering in favor of observation and treatment of its symptoms. In 1980, it hit on the strategy of adopting a medical rhetoric, organizing those symptoms into neat disease categories and checklists of precisely described criteria and publishing them in the hefty — and, according to its chief author, “very scientific-looking” — D.S.M.-III.

That book, with its more than 200 objectively described diagnoses, would have made Dr. Salmon proud. By meeting the scientific demands of the day, it was credited by many with having rescued psychiatry from the brink of extinction, and its subsequent revisions have been the cornerstone of the profession’s survival as a medical specialty.

But as all those Diagnostic and Statistical Manuals have stated clearly in their introductions, while the book seems to name the mental illnesses found in nature, it actually makes “no assumption that each category of mental disorder is a completely discrete entity with absolute boundaries dividing it from other mental disorders or no mental disorder.” And as any psychiatrist involved in the making of the D.S.M. will freely tell you, the disorders listed in the book are not “real diseases,” at least not like measles or hepatitis. Instead, they are useful constructs that capture the ways that people commonly suffer. The manual, they go on, was primarily written to give physicians, schooled in the language of disease, a way to recognize similarities and differences among their patients and to talk to one another about them. And it has been fairly successful at that.

Still, “people take it literally,” one psychiatrist who worked on the manual told me. “That is its strength in a political sense.” And even if the A.P.A. benefits mightily from that misperception, the troubles on the front page are not the organization’s fault. They are what happens when we expect the D.S.M. to be what it is not. “The D.S.M. has been taken too seriously,” another expert told me. “It’s the victim of its success.”

Psychiatrists would like the book to deserve a more serious take, and thus to be less subject to these embarrassing diagnostic squabbles. But this is going to require them to have what the rest of medicine already possesses: the biochemical markers that allow doctors to sort the staph from the strep, the malignant from the benign. And they don’t have these yet. They aren’t even close. The human brain, after all, may be the most complex object in the universe. And the few markers, the genes and the neural networks, that have been implicated in mental disorders do not map well onto the D.S.M.’s categories.

“We’re like Cinderella’s older stepsisters,” a psychiatrist told me the other day. “We’re trying to stick our fat feet into the delicate slipper so the prince can take us to the ball. But we ain’t going to the ball right now.” Which is why we might feel a little sorry for the beleaguered A.P.A.

On the other hand, given that the current edition of the D.S.M. has earned the association — which holds and tightly guards its naming rights to our pain — more than $100 million, we might want to temper our sympathy. It may not be dancing at the ball, but once every mental health worker, psychology student and forensic lawyer in the country buys the new book, it will be laughing all the way to the bank.

Gary Greenberg, a psychotherapist and the author of “Manufacturing Depression,” is writing a book about the making of the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders.

Source: http://www.nytimes.com/2012/01/30/opinion/the-dsms-troubled-revision.html?_r=1&emc=tnt&tntemail1=y

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I Had Asperger Syndrome. Briefly.

By Benjamin Nugent

FOR a brief, heady period in the history of autism spectrum diagnosis, in the late ’90s, I had Asperger syndrome.

Asperger's syndromeThere’s an educational video from that time, called “Understanding Asperger’s,” in which I appear. I am the affected 20-year-old in the wannabe-hipster vintage polo shirt talking about how keen his understanding of literature is and how misunderstood he was in fifth grade. The film was a research project directed by my mother, a psychology professor and Asperger specialist, and another expert in her department. It presents me as a young man living a full, meaningful life, despite his mental abnormality.

“Understanding Asperger’s” was no act of fraud. Both my mother and her colleague believed I met the diagnostic criteria laid out in the American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition. The manual, still the authoritative text for American therapists, hospitals and insurers, listed the symptoms exhibited by people with Asperger disorder, and, when I was 17, I was judged to fit the bill.

I exhibited a “qualified impairment in social interaction,” specifically “failure to develop peer relationships appropriate to developmental level” (I had few friends) and a “lack of spontaneous seeking to share enjoyment, interests, or achievements with other people” (I spent a lot of time by myself in my room reading novels and listening to music, and when I did hang out with other kids I often tried to speak like an E. M. Forster narrator, annoying them). I exhibited an “encompassing preoccupation with one or more stereotyped and restricted patterns of interest that is abnormal either in intensity or focus” (I memorized poems and spent a lot of time playing the guitar and writing terrible poems and novels).

The general idea with a psychological diagnosis is that it applies when the tendencies involved inhibit a person’s ability to experience a happy, normal life. And in my case, the tendencies seemed to do just that. My high school G.P.A. would have been higher if I had been less intensely focused on books and music. If I had been well-rounded enough to attain basic competence at a few sports, I wouldn’t have provoked rage and contempt in other kids during gym and recess.

The thing is, after college I moved to New York City and became a writer and met some people who shared my obsessions, and I ditched the Forsterian narrator thing, and then I wasn’t that awkward or isolated anymore. According to the diagnostic manual, Asperger syndrome is “a continuous and lifelong disorder,” but my symptoms had vanished.

Last year I sold a novel of the psychological-realism variety, which means that my job became to intuit the unverbalized meanings of social interactions and create fictional social encounters with interesting secret subtexts. By contrast, people with Asperger syndrome and other autism spectrum disorders usually struggle to pick up nonverbal social cues. They often prefer the kind of thinking involved in chess and math, activities at which I am almost as inept as I am at soccer.

The biggest single problem with the diagnostic criteria applied to me is this: You can be highly perceptive with regard to social interaction, as a child or adolescent, and still be a spectacular social failure. This is particularly true if you’re bad at sports or nervous or weird-looking.

As I came into my adult personality, it became clear to me and my mother that I didn’t have Asperger syndrome, and she apologized profusely for putting me in the video. For a long time, I sulked in her presence. I yelled at her sometimes, I am ashamed to report. And then I forgave her, after about seven years. Because my mother’s intentions were always noble. She wanted to educate parents and counselors about the disorder. She wanted to erase its stigma.

I wonder: If I had been born five years later and given the diagnosis at the more impressionable age of 12, what would have happened? I might never have tried to write about social interaction, having been told that I was hard-wired to find social interaction baffling.

The authors of the next edition of the diagnostic manual, the D.S.M.-5, are considering a narrower definition of the autism spectrum. This may reverse the drastic increase in Asperger diagnoses that has taken place over the last 10 to 15 years. Many prominent psychologists have reacted to this news with dismay. They protest that children and teenagers on the mild side of the autism spectrum will be denied the services they need if they’re unable to meet the new, more exclusive criteria.

But my experience can’t be unique. Under the rules in place today, any nerd, any withdrawn, bookish kid, can have Asperger syndrome.

The definition should be narrowed. I don’t want a kid with mild autism to go untreated. But I don’t want a school psychologist to give a clumsy, lonely teenager a description of his mind that isn’t true.

Benjamin Nugent, the director of creative writing at Southern New Hampshire University, is the author of “American Nerd: The Story of My People.”

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Proposed DSM 5 Changes and Autism: What Parents & Advocates Need to Know

by Lee Anne Owens

Proposed DSM 5 Changes and Autism: What Parents & Advocates Need to KnowIn May of 2013 the new diagnostic criteria for Autism Spectrum Disorder will be distributed to doctors via the fifth version of the Diagnostic and Statistical Manual of Mental Disorders (DSM 5). Think of the DSM 5 as the Bible of diagnostic criteria, developed and written by the American Psychiatric Association (APA).

One of the most discussed changes in the DSM 5 Autism Spectrum Disorder (ASD) is the removal of Asperger’s syndrome and PDD-NOS as individual diagnoses. Under the new diagnostic criteria, Asperger’s and PDD-NOS will come under the umbrella of ASD. For example a child whose diagnosis is currently Asperger’s syndrome would receive a new diagnosis of Autism Spectrum Disorder with specifiers included, such as “Autism Spectrum Disorder with fluent speech” or “Autism Spectrum Disorder with intellectual disability.” According to Dr. Bryan King, of the APA’s Neurodevelopmental Disorders Workgroup, this change could mean a decrease in the differentiation of services available to those previously diagnosed with Asperger’s syndrome. (http://autism.about.com/od/diagnosingautism/a/Why-Asperger-Syndrome-Will-Disappear.htm) In layman’s terms this means that some children will benefit from a greater availability of needed services because they have a diagnosis of ASD, rather than Asperger’s.

Read the Rest of this Article on SpecialEducationAdvisor.com

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